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 2 Million Dollars Question: Real Case  

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Author31 Posts

2 million dollars


17 year-old male presented to the ER on Friday night escorted by the police c/o coughing up blood about 2 teaspoons of bright red blood after meal. He was playing card after dinner in the jail. PMH: unremarkable SH: hx of marijuana use FH: unremarkable.

VS stable

Lab CBC: nl electrolytes nl

Pt was admitted to ICU, seen by hte GI and had endocscopy on Saturday morning and found to have Mallory-Weiss Syndrome. Pt remained stable and was transferred to the floor on Sunday. Pt then had massive hemoptysis around 1 p.m. and became hypotensive, decreased mental status and transferred back to ICU. 4 units of packed RBC, FFP were transfused. Pt died on Tuesday at age 17 years old. Family sued the hospital, attending doctors and you for 2 million dollars.

What is the diagnosis?


What would you do? What test would you do ?


You may never see this case and all the doctors in the entire world may never see this case. But I was the senior resident and the case dragged on for 4 years !

So show me you deserve to practice in America !

Show me how to understand the medical-legal problems in United States !

Show me the medical ethics in this case !

The State sent a lot of prisoners to you and 80% are malingering and fake but this one is real. How do you show which prisoner, federal, state or local inmate is real or fake ?

The Kaplan, Harrison, Q book will never teach you this ! Hahaha Welcome to real medicine !


Actually don't get your question... there are clear criteria to suspect malingering, and having hemoptysis is not one. So the "legal and ethic" answer will be... do your job.

A young man that does drugs (marijuana and who knows what else), in jail, with cough and hemoptysis... must rule out AT LEAST tuberculosis. Hard to tell what really happened, and why, I'll appreciate if you enlighten the issue.


The 17 year-old was in jail for just a few days.

And you have to visit many American jails,

the prisoners get "UNIVERSAL FREE CARE".

You know what that means. All prisoners receive free medication and free medical care.

now go back to this young man with acute hemoptysis. And acute upper GI bleeding.

Please give me the differential diagnosis.

Give me your two-cents. Come on.

Guys. You want to be a doctor in America, then welcome to the real American patients !

tell me what are you going to do !


Mnay prisoners try to get away from "heat" "pressure" by cutting their wrists, or do something to harm themselves to avoid "a contracted murder" on them.

But this young man c/o of hemptysis with 2 teaspoons of bright red blood, documented by the jailers amd I did see him vomiting blood all over the floor.

The entire floor was covered with blood, blood every where.

Now tell me the diagnosis.

Come on. TB. You must study too much !

Think. What did I teach you for the last 2 months.

First, I teach you when you approach a question, age and gender.

Age: Male

Gender: male

The jail has nothing, nothing to do with his hemoptysis.

Forget the TB , so give me the diagnosis. Come on.

You are going to see more and more of this kind of problems. !


I am going to cut you some slacks !

As medicine advances to the

cutting edge, you are going to see

more and more adult congenital

problems including heart diseases.

Many patients died in utero but now they survive in teens and presents

symptoms very late. As in this case, I gave away my answer.

Think what I say !


Dude… what is your problem!!

<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

I’m sorry if you had that bad experience, but if you want to formulate a question from it I think you should present more relevant info. So, if some congenital problem was the cause, then something in the question must at least suggest such thing… I am aware that extraordinary cases like yours appear in real life, but don’t forget this is still a STEP 2 CK forum. The “a man in the middle of the street drop dead… what is the diagnosis, pathologic findings, and how can U prevent it” type of question, don’t think helps many people preparing for the exam, which is the reason why they are here… It may help to increase your ego and sense of superiority (as you think you are everybody’s teacher), by showing some of your broad professional experience…

And by the way… don’t think that you are entitled to ask proof of worthiness to enter the <?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" />US…so stop asking for my cents =D.


very well said isther...i could'nt have put it better myself.

AAAAA, as much as we appreciate new discussions and see them as a means of learning something new and chisel our way of thinking and our approach to the patient, i think it is not the best attitude when you refer to people on the forum like only you can...

and what is this thing about " what did i teach you" and being a self proclaimed teacher and why do you have a problem if people are coming to the US...they will and they surely deserve to be and they don't need to prove that to anyone here on the forum...they clear their exams, get through what needs to be done for the exam and contribute to the society as much as anyone later on in life... you have some issues man and you need to get over with them within yourself...pls dont let out your frustations here on the forum. they are not appreciated.


AAAAA, I don't know what the patient you mention has, but you seem to be suffering from a case of Megaloblastic Egoma.


well aaaaa
u obviously are intelligent and know ur stuff
however-u do have a SERIOUS attitude problem!!!
quite frankly--im not even sure how u managed all the things u said u have with ur remarkable penchant for rubbing people the wrong way---i mean a hospital runs as a team--and that requires understanding and cooperation!!
I presume ur not an international medical graduate--n therein for some reason lies your intense dislike of the people here who are--WHY for god sakes??

U had the LUCK to be born here--it was NOT something u earned!!
All the people on this forum are sacrificing a lot of time ,effort and peace of mind to do these exams--they understand their importance and just bcause they may have a different nationality--it does NOT mean they are inferior to u.
I myself am a junior person--still a noob when it comes to medicine--however--many of those on this forum are those with post-graduate degrees in their home country--they have already put in a lot of effort and proven themselves--IMAGINE how hard it is for them to leave this all and go through all this again--and then go through residency again!!!--but they are all committed and willing to do what it takes to get there--i think that merits praise--not the contempt u seem to have for them!!

Are u afraid theyll take ur job???--thats really stupid if thats the case--if ur 1/2 as good as u claim to be --u shouldnt be worried at all!!!!

And btw--everyone here CHOSE to become a doctor--they all have the necessary respect and empathy for patients--they are not here to EXPLOIT americans!!!
Finally we all care too that the patient gets the best!!

And herein lies the real problem--from what i have seen on this forum--U AAAAA can definitely be a real asset and help everyone improve themselves--however even if that really is ur intention--the way u go about it only causes irritation and resentment!

We are not here as some contest--where u childishly seem to find great glee in finding faults with others--help everyone improve!!!

i myself have been helped by ur posts--however they have also been very irritating at times

so the request is simple--keep up the good work and CUT OUT the contempt
We will all really respect u for that if u do!!!!

I hope u see the light!!


AAAAA, I agree with other guys in 100%.
I don't know how broad is your clinical experience, but it's worth nothing if you can't communicate with other people, especially with your colleagues; and you can't, because you don't respect them and think that you can decide whether they deserve or not to practice medicine in the US - you are trying to show this in every single post you have created on this forum; your remarks are offensive - do you think that people like it? if you think so, you surely have some psychological problems. disapproval

Edited by p53 on Jun 04, 2006 - 11:29 PM


AAAAA wrote:
Mnay prisoners try to get away from "heat" "pressure" by cutting their wrists, or do something to harm themselves to avoid "a contracted murder" on them.

But this young man c/o of hemptysis with 2 teaspoons of bright red blood, documented by the jailers amd I did see him vomiting blood all over the floor.

The entire floor was covered with blood, blood every where.

Now tell me the diagnosis.

Come on. TB. You must study too much !

Think. What did I teach you for the last 2 months.

First, I teach you when you approach a question, age and gender.

Age: Male

Gender: male

The jail has nothing, nothing to do with his hemoptysis.

Forget the TB , so give me the diagnosis. Come on.

You are going to see more and more of this kind of problems. !

Just tell me how come that 2 teaspoons of blood would cover entire floor ?(look up,guys).
You clearly are a PSYCHO and I suggest serious professional help!!!!
AS for the question per se-Esophageal varices,may be from cirrhosis as from RHF or whatever else(could be due to congenital HD but doesn't prove anything),the POINT is that whatever has been done in Th way is as much as you actually CAN do!
And as far as law suits go in the States-well,that'll always happen even for less reasons than this one,
Bu one thing is certain:YOU NEED A PSYCHIATRIST!


Thanks to isther for finally saying what many people on this forum have been thinking for quite some time!


Calm down doctors.Lets not waste our time on useless debates.AAAAA man you have a very reasonable question there that these cases do come into emergency and if we are planning to be a part of US medical system,we need to know all this too.Although our residency programms pay our insurances,but still you never want a law suit against you in your resume.The thing we all feel here is that you are not able to phrase the topic in appropriate words and so no body is able to understand what the topic of discussion is.There is nothing wrong with the question you are asking,but let us discuss it in a discussion mode as u try to explain what's the essence of the case and what u think about it..may be once we understand ,we will be able to throw some more light on the great topic you started.Chill !!!


Alright guys...I guess the point has been put across.Lets all calm down and make the most of the time each of us spends here. said by everyone above...we do appreciate your posts but somehow there is a derogatory element in them.I am not sure if you're aware of it yourself but lets just not have any more outbursts here.

As for the question...I am stumped.Some more insight into this would surely be of help.


I guess someone mentioned right heart failure as a cause of cirrhosis and esoph varices. Sounds logical. But other signs of cirrhosis would be present.

Remember the words of the immortal Dr Conrad Fisher: "Angels fly... because they take themselves lightly" Don't make a big fuzz out of little things.


I did not read any of the above posts.

But I tell you this is all the information I got !

Nothing more ! A young man presented with acute hemoptyis and died !

The diagnosis is :

Aorto-esopheageal fistula.

(I was not born here but in Asia just like everyone.)

You will get this kind of real cases in the ER with little or no information. The exam may give you relevant information but in real life, the history is unreliable about 60% of the time.

Let's go back to this case.

Male starts bone spurt around 13 year-old and a normal male should be able to reach 3-4 cm bone spurt every year. Some more than 5 cm/yr.

But how about other organs including the heart. As the heart starts to beat at 21 days after the egg was fertilized. The heart probably will not reach the miximal size and physiological function by 17-18 years old.

This young man , a 17 year-old man probably had some kind of fibromuscular aorto-eopheageal fistula but in a rudimentary form.

As he aged, the fibromuscular fistula became stronger and probably reached its maximal strength by age 17-18 year old.

Along with the maturation of the fibromuscular fistula, the heart starts to reach maximal cardiac output and reach the maximal EF by age 17 to 18 year old and the pressure in the aorta forced the E-A fistula to open up around age 17.

The only pertinent history is the pt did used different kind of illicit drugs and whether this has anything to do with this A-E fistula, I don't know.

But the rise of the aorta pressure force open the A-E fistula and pt presented with massive GI bleeding.

This occurred at the General Hospital and by Tuesday morning, the pt underwent aortogram and the A-E fistula was found and an emergency cardiothoracic surgery was done at the unviersity center which is on the Wes End about 20 minutes from Downtown.

The young pt was operated on but died on the table secondary to multi-organ failure, hypotension, massive blood loss.

P.S. Not all prisoners who presented to ER did not have real medical problems.

This brings a very important point about elderly who had AAA repair aorto abdominal aneursym repair in the early 70's, 80's and mid 90's. Many developed aorto-colonic fistula and had massive lower GI bleeding.

For those pt, type and cross at least 4 units of RBC and call the surgeon. It is not the time for medical management.

Start 2 large bore of IV and transfuse blood and get the pt to OR.

The vacular surgeons had started using new graft in 1990's to repair AAA with special anti-epithelial growth factor so fistula will not form between the aorta and the colon.

Thanks for everyone !

If anyone has any information about congential aort0-esophegeal fistule, please contribute here.

We are here to learn and I understand what the book said but in real life, "we" all tend to ignore a drug-addict criminal who was arrested, convicted, and sentenced and waiting to be transferred to a Tenneesee prison but presented with a congenital aorto-esophegeal fistula.

Any comment is welcome.

The city, the Hospital, the University and Professors and me won the case ! Everything was done right despite a poor outcome. That's life. I just hope to share with you the experience I went through as a IMS international medical student. Yes, they do accept one to two international students through the official exchange programs.

For example, Saudia Arabia and many middle eastern schools paid millions as donation to medical schools to train their students either as medical students or as residents and all went home!


Step 2 do ask you about aorto-colonic fistula and lower GI bleeding in elderly with hx of AAA repair.

The saline point is any elderly with AAA repair and presented with lower GI bleeding, aorto-colocic fistula must rule out !

Thanks !


The pt presented with 2 teaspoon of bright red blod bleeding in the jail but had massive upper GI bleeding on the medicine ward after transfer on Sunday 1 p.m.


Aortoesophageal fistula and fatal rupture

Attached Files:
1649W.jpg (42 KB, 27 downloads)

The pt just can not tell me he had aortoesophageal fistula. Sorry, doc, please bring me to the OR and repair my fistula, I got aortoesophageal fistula and the pressure gradient exceeded the fibromuscular fistula opening pressure.

I understand I got no information to give you but that is the real situation he presented with !

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